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Wednesday, July 29, 2009

Prevention and the “Trap of Meaning”

The July 22/29 issue of JAMA contains a very interesting essay by Constantine Lyketsos and Margaret Chisholm titled “The trap of meaning: a public health tragedy”[1] (http://jama.ama-assn.org/cgi/content/full/302/4/432?home). The article starts with two obituary quotes:“Adolf Merckle, the German billionaire whose speculation in volatile Volkswagen stock had pushed his sprawling business empire to the edge of ruin, has committed suicide. . . . "No longer being able to handle the situation . . . he ended his life," the family said.John Updike, the kaleidoscopically gifted writer . . . died. . . . The cause was cancer.”

They go on to note that the picture of Updike that accompanied the picture showed him with a lighted cigarette, but that the obituary did not suggest that this may have been the cause of his cancer and death. Their point is that, where mental illness and particularly depression are concerned, and especially when these diseases are terminal through suicide, we seek meaning in the objective facts – that Merckle committed suicide because his was disconsolate at the results of his actions, rather than that he was depressed. “Of course, he was depressed,” we might think, “look at what he did and what happened from it.” We like such explanations, as the authors point out “because they have face validity and make sense.” But, on the whole they are wrong, or at least incomplete. For each Adolf Merckle who commits suicide after bringing ruin upon himself, his family and his company, we have many corporate and financial titans who have not. Some may be sad, and some may even be recondite, while others feel unfairly persecuted, entitled, arrogant, and every other possible human response, but most have not committed suicide. What made Merckle different?

Although, I – like Lyketsos and Chisholm – know nothing about the actual medical history of Merckle or Updike, there is a strong possibility that the reason for Merckle’s death was depression, just as there is a there is such a possibility that Updike’s was related to his smoking. When I started the article I thought that the authors were going to talk about how we accept depression but think of smoking as a “behavior”, while they in fact went on the opposite track; this may reflect my increased sensitivity to the issue of depression as terminal disease, which many others may not share.[i] Yes, it is possible or probable that specific life events may trigger the completion of suicide in a person afflicted with depression, but they do not cause it any more that the simple upper respiratory infection leading to pneumonia in a person with chronic lung disease “causes” the death of that long-time smoker. The same trigger, the upper respiratory infections or adverse life events, may inconvenience those of us who are relatively healthy, or in the case of severe viral infections (such as influenza) or serious adverse life events (financial ruin, divorce, death of a loved one) have severe effects upon us, but they do not kill us absent the underlying disease. Depression, a biochemical imbalance in the brain, like chronic lung disease, can be more or less severe, but it is all too frequently fatal.

The most important point that Lyketsos and Chisholm make is that the search for “meaning” in actions such as suicide – that someone killed themselves because they were unhappy because of financial losses, or family losses, other life events – not only is largely wrong, or inadequate, as an explanation, but that it may in fact increase the mortality of the disease. This is because those who suffer from depression, as well as their friends and family, in their search for an explanation, for meaning, for a “cause” in the external events of life, may fail to recognize, deny, or not treat the underlying disease of depression. It is in many ways parallel to high blood pressure: it can be made worse by life circumstances, mild forms may be controlled without drugs, more severe forms usually require drugs, and even those who are treated may still succumb to effects of the disease.

Depression, like many other chronic diseases, is not always successfully treatable. People who clearly recognize their disease, are in therapy, and are on medication may still commit suicide, just as those under treatment for hypertension or heart or lung or kidney disease may succumb. Many people are in denial about their diseases, whether those diseases are of the heart, lung, kidney, or brain. We have talked about many (often defined as “cultural”) beliefs about cause of disease that are not consistent with science and biology. But the type of denial that characterizes depression, couched in the search for “meaning” in life events, is less frequently seen nowadays in conditions seen as more physical. “The trap of meaning,” write Lyketsos and Chisholm, “is a formidable challenge because it feeds off an adaptive human predilection”. That means that people like explanations. The danger is when those explanations are wrong, and blind us to the correct diagnosis and potentially helpful therapy.

[i] In full disclosure, I am definitely not dispassionate about this issue. One of the kindest, smartest and most gentle people I have ever known, as well as someone I loved with all my heart, committed suicide. While those of us who knew him over many years were aware of “episodes” of depression, we obviously did not understand how profound it was. When my son, Matt, took his life at the age of 24, it was at a time when things were going very well in his life, as far as anyone else could see. He was in a strong, loving, committed relationship, about to graduate with a degree from school he loved and where the professors thought him outstanding, had a relatively recently diagnosed chronic physical illness – diabetes – under good control, and had big short and long term plans. He also, not typically but not uncommonly, did not make a suicide gesture, but rather planned it thoroughly and in private, driving to a far off state (where it was easy to buy the gun he used; probably the first time he ever used a gun) and taking enough cash that he could not be tracked by credit cards. He really wanted to do this, and people who were very close to him had no idea. I say all this because yes, if he could do this, then your friend or father or son or wife with depression could, even if they are doing great now.

This is the tragedy of depression, the risk that it will be written off with “reasonable explanations” or the “trap of meaning”. Recognizing it and treating it may not prevent a terminal outcome, but it is the best we can do, and a whole lot better than pretending it is not there.